Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
157 Cards in this Set
- Front
- Back
|
at what age does surgical risk increase
|
70
|
|
|
age should not be used as what
|
sole criteria to withhold surgery
|
|
|
what is relationship between exercise capacity and risk
|
as exercise capacity goes up risk goes down
|
|
|
what is poor exercise capacity
|
inability to walk four blocks or climb two flights of stairs
|
|
|
obesity alone is not what
|
risk factor for most major adverse postop outcomes
|
|
|
what is obesity a major postop risk factor for
|
DVT
|
|
|
what is one of the greatest nutritional concerns
|
protein status
|
|
|
what albumin level is a predictor of poor outcome
|
<2.2mg/dl
|
|
|
albumin is better marker for what
|
chronic protein depletion
|
|
|
transferrins is a better marker for what
|
acute protein deprevation
|
|
|
prealbumin is a better marker for what than albumin
|
acute protein depletion
|
|
|
what is a big complication of malnutrition postop
|
increased susceptibility to infection and poor wound healing
|
|
|
plavix should be discontinued how many days before surgery
|
7
|
|
|
what cardio meds should be continued perioperatively
|
nitrates, digoxin, beta-blockers, clonidine, calcium channel blockers, and antiarrhythmics
|
|
|
what is protocol with diuretics with surgery
|
hold in AM of surgery
|
|
|
what is protocol with ACEI and A2 receptor antagonists with surgery
|
hold in AM of surgery
|
|
|
what should happen with pulmonary meds during surgery
|
continued perioperatively
|
|
|
HRT is associated with what risk
|
increased risk of VTE
|
|
|
should HRT be discontinued
|
not if it is properly prophylaxed
|
|
|
what is the protocol for antidepressants in surgery
|
all should be continued perioperatively
-MAOI's, SSRI, Tricyclic antidepressants |
|
|
what is protocol with aspirin perop
|
should be discontinued 7-10 days preop
|
|
|
what is recommendation with NSAIDs preop
|
discontinued 3 days preop
|
|
|
how long does it take INR to fall below 2.0
|
at least two days
|
|
|
where should INR be maintained for patients using for thromboprophylaxis
|
1.5 prior to surgery
|
|
|
where should INR be maintained for patients with mechanical prosthetic valves
|
2.0
|
|
|
what is required for patients at high risk for thromboembolism perioperatively
|
coverage with unfractionated heparin or LMWH
|
|
|
what is protocol for reversing warfarin with fully elective surgery
|
INR btwn 2-3
warfarin witheld 3-4d to allow INR to fall between 1.5-2.0 |
|
|
what is protocol for reversing warfarin for semi-urgent surgery
|
reveral in 1-2d
warfarin witheld small dose IV vit K 1-2mg |
|
|
what is protocol for reversing warfarin for urgernt surgery
|
reveral in less than one day
warfarin witheld larger dose IV vit K 2.5-5.0mg |
|
|
what is protocol for reversing warfarin for immediate reversal
|
reversal in min to hrs
fresh frozen plasma or a prothrombin complex concentrate in addition to vit K |
|
|
what is bridging anticoagulation
|
perioperative prophylaxis with unfractionated heparin or LMWH
|
|
|
when should bridging anticoagulation be considered
|
high risk patients
|
|
|
who is considered high risk for VTE
|
VTE in previous 4 wks, active malignancy, prosthetic valve in mitral valve
|
|
|
how should lab tests be used in evaluation
|
selective rather than routine
|
|
|
MCV and RDW can be helpful in determining what
|
if blood loss is chronic or acute
|
|
|
low hematocrit, low MCV and normal RDW is indicative of what
|
chronic iron-deficient erythropoiesis
|
|
|
low hematocrit, low MCV and high RDW suggests what
|
more acute blood loss
|
|
|
when is baseline HB/HCT recommended
|
over 65 undergoing major surgery
younger patients if major blood loss is expected |
|
|
HB/HCT not necessary for minor procedures unless what
|
history is suggestive of anemia
|
|
|
when should CBC be screened
|
symptoms of infection
diffuse lymphadeopathy or splenomegaly myelodysplastic disease or leukopenia related to drugs |
|
|
when should platelets be screened
|
Hx of bleeding or bruising
myeloproliferative disease chemotherpay agents medications |
|
|
PTT measures which pathway
|
intrinsic pathway
|
|
|
PTT monitors therapy of what drug
|
heparin
|
|
|
PT measures which pathway
|
extrinsic pathway
|
|
|
PT measures which factors
|
2, 5, 7, 10 and fibrinogen
|
|
|
Normal INR
|
1.0
|
|
|
Warfarin INR
|
2.0-3.0
|
|
|
when should PT/PTT be screened
|
chronic liver disease
malnutrition, genetic/hemophilia, vitamin/clotting deficiency, medicine |
|
|
BMP
|
BUN, CO2, Cr, Glucose, Serum Cl, Serum K, Serum Na
|
|
|
what is serum Cr>2.0mg/dl a independent risk factor for
|
postop pulmonary complications
|
|
|
renal insufficiency is a independent risk factor for what
|
postop pulmonary complications and a major predictor of postop mortality
|
|
|
when is it reasonable to get serum Cr concentration
|
if patient is over 50 when major surgery is planned
if hypotension is likely when nephrotoxic drugs will be used |
|
|
CMP
|
BMP+
Ca, serum albumin, serum total protein, alkaline phosphatase, alanine amino transferase, aspartate amino transferase, bilirubin |
|
|
what are the theoretical reasons to have a urinalysis preformed preop
|
identify unsuspected renal disease
identify urinary tract infection |
|
|
when is urinalysis not usually recommended
|
in asymptomatic patients
|
|
|
what is the importance of electrocardiogram preop
|
detection of recent myocardial infection
|
|
|
recent myocardial infarction carries what risk in surgery
|
high surgical morbidity and mortality surgical risk
|
|
|
what patients should have routine preoperative ECGs
|
Men>45
Women>55 known cardiac disease clinical eval suggests possible cardiac disease risk for electrolyte abnormalities, diuretic use systemic disease assoc with possible unrecognized heart disease (DM or HTN) undergoing major surgical procedure |
|
|
when would you order preop chest radiographs
|
>50yrs undergoing major surgery
suspected cardiac or pulmonary problems |
|
|
what should be included in preop assessment of diabetics
|
baseline ECG and assessment of renal function
|
|
|
when should surgeries be scheduled with diabetics
|
in the AM
|
|
|
when does risk of postop infection increase in correlation with A1C
|
above 7
|
|
|
goals for glycemic control perioperatively
|
maintain fluid and electrolyte balance
prevention of ketoacidosis avoidance of marked hyperglycemia avoidance of hypoglycemia |
|
|
what is treatment for type 2 diabetics perioperatively
|
generally no treatment needed
|
|
|
what is protocol with type 2 treated with oral hypoglycemic
|
on morning hold hypoglycemic drugs
drugs can be restarted postop when patient starts eating again |
|
|
what is protocol for type 1 or insulin treated type 2 diabetic
|
omit short acting insulin on morning of surgery and give 1/2 or 2/3 of intermediate or long acting insulin
start dextrose containing solution IV at rate of 75-125cc/hr to provide 3.75-6.25 g/hr |
|
|
when should preop trmnt regement be reinstated postop
|
once patient is eating well
|
|
|
metformin should not be restarted in what patients
|
patients with renal insufficiency, significant hepatic impairment, or CHF
|
|
|
when should sulfonylureas be restarted
|
only when eating has been well established
|
|
|
when should thiazolidinediones not be used
|
if patients dvlp CHF, problematic fluid retention, any liver fxn abnormalities
|
|
|
RA patients may have what problems
|
cervical joint involvement and problems with intubation
|
|
|
what should be obtained with RA patients
|
lateral cervical spinal radiographs with flexion and extension views
|
|
|
what complications can long term use of corticosteriods cause
|
impaired wound healing, increased friability of skin or superficial blood vessels, mild pressure may cause hematoma or skin ulceration, adhesive skin may tear skin, increased risk of fracture, infections, gi hemorrhage or ulcer
|
|
|
ankylosing spondylitis may cause problems with what
|
regional anesthesia, endotrachial intubation, increased risk of infection
|
|
|
koebners phenomenon
|
psoriatic flare at sight of operation
|
|
|
SLE increases the risk of what postop
|
wound infection, renal insufficiency, pulmonary embolus,
|
|
|
some SLE patients have antiphospholipid antibodies that increase the risk of what
|
thrombosis
|
|
|
beware of what with SLE
|
thrombocytopenia
|
|
|
when should smoking be stopped before surgery
|
8 wks
|
|
|
what should be done for patients with clinically significant COPD
|
inhaled ipratropium, or tiotropium
|
|
|
what should be done for patients with COPD and wheezes or dyspnea
|
inhaled beta agonists
|
|
|
what things should be checked with alcoholic patient
|
hydration status, nutritional status, withdrawl and DTs
|
|
|
most clean procedures do not require what
|
anitmicrobial prophylaxis unless there is high risk of infection or consequences of SSI are disastrous
|
|
|
what is a good choice for prophylaxis of a clean procedure
|
1st gen cef
cefazolin |
|
|
what is an alternative choice for thoracic and orthapedic clean procedures
|
2nd gen cef
cefuroxime |
|
|
what can most patients with penicillin allergy be prophylaxed with
|
cefazolin
|
|
|
what are good prophylaxis choices when cefs can't be used do to allergy
|
vancomysin and clindamysin
|
|
|
when should prophylaxis begin
|
within 60 min prior to incision
|
|
|
when should prophylaxis begin with vanco or flouroquinones
|
within120 min prior to incision
|
|
|
how many doses are required for procedures lasting less than 4 hrs
|
only one dose
|
|
|
what might be the effects of repeat prophylaxis doses after wound closure
|
increase antimicrobial resistance
|
|
|
what do guidlines suggest for handy hygiene
|
alcohol based hand rub or antimicrobial soap
|
|
|
how should hair be removed prior to surgery
|
clipped rather than shaved
|
|
|
mild perioperative hypothermia may promote what
|
SSI by triggering thermoregulatory vasoconstriction that may in turn decrease subq oxygen tension
|
|
|
what are the four classifications of surgical wounds
|
clean, clean-contaminated, contaminated, dirty
|
|
|
clean wound
|
uninfected operative wounds no inflammation encountered, wound closed primarily
|
|
|
clean contaminated wound
|
operative wounds in which a viscus (respiratory, alimentary, genital, urinary) was entered under controlled conditions and without unusual contamination
|
|
|
contaminated wound
|
open fress accidental wounds operations with major breaks in sterile tech or gross spillage from a viscus wounds with acute purulent inflammation
|
|
|
dirty wound
|
old traumatic wounds with retained devitalized tissue foreign bodies or fecal contamination or wounds that involve existing clinical infection or perforated viscus
|
|
|
ASA class 1
|
healthy patient with no disease outside the surgical process
|
|
|
ASA class 2
|
mild/moderate systemic disease medically well controlled no functional limitation
|
|
|
ASA class 3
|
severe systemic disease process which results in functional limitation but is not incapcitating
|
|
|
ASA class 4
|
severe incapacitating disease process that is a constant threat to life
|
|
|
ASA class 5
|
moribund patient not expected to survive 24 hrs with or without an operation
|
|
|
ASA Class E
|
suffix to indicate emergency surgery for any class
|
|
|
minimal sedation affects what areas
|
responsiveness
|
|
|
what are the goals of anesthesia
|
amnesia
analgesia neuromuscular blockade maintenance of physiologic homeostasis |
|
|
what is malignant hyperthermia triggered by
|
exposure to volatile/gas anesthetics and succinylcholine
|
|
|
susceptibility to MH is often what
|
inherited autosomal dominant
|
|
|
what are symptoms and signs of malignant hyperthermia
|
muscular rigidity, hypermetabolic state, hyperthermia, increased oxygen consumption, hypercapnia, rhabdomyolysis
|
|
|
how is malignant hyperthemia treated
|
dantrolene
|
|
|
how does dantrolene work
|
muscle relaxant that appears to work directly on the ryanodine receptor to prevent the release of calcium
|
|
|
what is the protocol on chronic antihypertensive meds
|
should be taken up til the morning of surgery
|
|
|
what antihypertensive drugs should not be stopped abruptly
|
beta blockers and centrally acting agents like clonidine
|
|
|
how is postop N/V treated
|
treated to prevent
IV 1.25mg droperidol and 4mg of dexamethasone withing 20 min of start of anethesia |
|
|
what are the strategies to reduce postop pulmonary complications
|
deep breathing exercises epidural analgesia in place of parenteral opiods
|
|
|
postop ileus
|
obstipation and intolerance of oral intake resulting from a nonmechanical insult that disrupts the normal corrdinated propulsive activity of the GI tract
|
|
|
how is postop ileus diagnosed
|
symptoms lasting for more than 3-5 days postop
|
|
|
SSI defined by CDC
|
infections related to the operative procedure that occur at or near the surgical incision within 30 days of an operative procedure or within one year if an implant is left in place
|
|
|
what is most common source of SSI
|
direct innoculation of endogenous patient flora
|
|
|
what are most common pathogens of SSI
|
normal skin flora including staph and coagulase negative staphylococci
|
|
|
what are the most important factors in preventing SSI
|
general health of patient
meticulous operative techniques timely administration of preoperative antibiotics |
|
|
what is fundamental in lowering SSI rates
|
good surgical technique
|
|
|
what are some good practices of good surgical technique
|
gentle traction
effective hemostasis, removal of devitalized tissue, obliteration of dead spaces, irrigation of tissues to avoid excessive drying, wound closure without tension, judicious use of closed suction drains, non-absorbable monofilament suture material |
|
|
what are the recommendations to reduce teh incidence of SSIs
|
appropriate use of antibiotics
appropriate hair removal maintenance of glucose control establish perioperative normothermia |
|
|
what are the causes of immediate onset of fever after surgery
|
medications or blood products
malignant hyperthermia trauma prior to or during surgery infection present prior to surgery |
|
|
causes of acute onset of fever within 1st week postop
|
SSI
pneumonia aspiration UTI pancreatitis, myocardial infarction, pulmonary embolism, thrombophlebitis, alcohol withdrawl, acute gout |
|
|
Subacute onset of fever 1-4 wks post op
|
SSI
drug reactions thrombophlebitis, DVT, PE |
|
|
Delayed onset fever more than one month after surgery
|
viral infections from blood products
indolent microorganisms especially in implant devices infective endocardititis |
|
|
most common causes of infectious postop fever
|
SSI, pneumonia, UTI, Intravascular catheter infection
|
|
|
most common causes of non-infectious postop fever
|
medication reaction
|
|
|
most common drug reactions causing post op fever
|
antimicrobials and heparin
|
|
|
what is the approach to patient with postop fever
|
Wind, Water, Wound, What did we do
|
|
|
wind
|
pneumonia, aspiration, pulmonary embolism
|
|
|
water
|
UTI
|
|
|
wound
|
SSI
|
|
|
what did we do
|
meds, transfusions, intravascular nasal, urethral, abdominal catheters
|
|
|
what tests should be ordered with postop fever
|
chest radiograph, urinalysis, blood and urine cultures, cbc with diff, esr, crp
|
|
|
treatment of postop fever
|
scheduled acetaminophen
discontinue any unnecessary meds, catheters etc |
|
|
classic symptoms of DVT
|
swelling, pain, and discoloration of involved extremity
|
|
|
what symptom has highest predictive value of DVT
|
difference in calf diameters
|
|
|
what tests are used in diagnosis of DVT
|
duplex doppler
d-dimer assay |
|
|
what are risk categories for DVT
|
low, moderate, high
|
|
|
what are risk factors for DVT
|
older age, previous thromboembolism, coexistence of malignancy or medical illness, thrombophilia, longer surgical anesthesia, and immobilization times
|
|
|
low risk for DVT
|
<40 no risk factors general anesthesia less than 30 min, minor elective abdominal or thoracic surgery
|
|
|
moderate risk for DVT
|
>40, sx for malignancy or orthopedic surgery of lower extremity lasting more than 30 min, inhibitor deficiency state or other risk factor
|
|
|
what are risk factors for DVT
|
older age, previous thromboembolism, coexistence of malignancy or medical illness, thrombophilia, longer surgical anesthesia, immobilization times
|
|
|
prevention of a hematoma
|
anatomical dissection, meticulous hemostasis, firm compressive dressing, closed suction drainage, gentle warming, ROM exercises
|
|
|
treatment for postop white toe
|
place patient in trendelenberg or foot in dependent position
loosen postop dressing gentle warming, local anesthetic, nitropaste, loosen/remove k-wire |
|
|
hallux varus
|
transverse plane medial deviation of hallux with the apex at the 1st mpj
|
|
|
causes of hallux varus
|
aggressive plantar lateral rls/fibular sesamoidectomy, staking of met head, overcorrction of deformity, aggresive resection of medial capsule
unrecognized increase in DASA or HIA |
|
|
delayed union
|
failure to fuse 2-6 mo
|
|
|
non union
|
failure to fuse 6-8 mo
|
|
|
medicare defined non-union
|
fracture healing has ceased for 3 or more months
must be documented by a minimum of 2 sets of radiographs seperated by a minimum of 90 days with no evidence of healing between |
|
|
where are non-unions more common
|
in fusions rather than osteotomies
|
|
|
risk factors for non union
|
systemic, local, early weightbearing,
|
|
|
tx for non union
|
immobilization, bone stimulators, surgery-grafting
|
